Effectiveness of communicative and educative strategies in chronic low back pain patients: A systematic review

Assessing the mediating role of disenfranchising talk on the well-being of female patients with chronic overlapping pain conditions

OBJECTIVE

Disenfranchising talk (DT) occurs when health care providers discredit, silence, and stereotype patients. Although ample research has suggested associations among negative patient-provider interactions and poorer well-being, this study is the first to investigate the mediating role of patient-provider DT in exacerbating poorer pain-related health correlates.

METHODS

Female patients living with chronic overlapping pain conditions (N = 348) completed a cross-sectional survey including measures of DT, pain severity, pain catastrophizing, and pain disability, as well as demographic information. Structural equation modeling in AMOS 29 assessed whether DT mediated the relationship between age, educational attainment, and sexual orientation (demographics), and pain severity, catastrophizing, and disability (pain-related health correlates).

RESULTS

Structural equation modeling revealed that DT mediated the relationship between age, educational attainment, and sexual orientation on pain-related health correlates, such that younger and LGBQA+ patients and those with less educational attainment reported heightened pain severity, catastrophizing, and disability when they also reported DT.

CONCLUSION

In contrast to scholarship assessing how demographics and pain-related variables influence patient-provider communication, this study instead investigated the mediating role of DT in pain-related health correlates.

PRACTICE IMPLICATIONS

Providers should avoid discrediting, silencing, or stereotyping female chronic pain patients' pain to potentially avoid exacerbating pain-related health correlates.

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF)

BACKGROUND

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.

AIM

To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.

DESIGN

Clinical practice guideline.

SETTING

Inpatient and outpatient.

POPULATION

Adults with LBP and/or LRS.

METHODS

Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.

RESULTS

The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.

CONCLUSIONS

An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.

CLINICAL REHABILITATION IMPACT

This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Pain neuroscience education and graded exposure versus Pilates and postural education: A pilot study in an occupational context

INTRODUCTION

Pain neuroscience education (PNE) and graded exposure have not been explored in occupational settings for low back pain (LBP).

AIM

To pilot feasibility and assess preliminary effectiveness of PNE and graded exposure for LBP.

METHODS

A pilot study where workers were randomized to either PNE and graded exposure or Pilates and postural education. Both interventions consisted of weekly individual face-to-face sessions for 8 weeks (a total of 8 sessions). The primary outcome was pain intensity. Secondary outcomes were disability, catastrophizing, fear-avoidance, sleep, endurance of back extensor muscles, and patient's perceived impression of change.

RESULTS

Seventeen participants entered the PNE and graded exposure group and 20 the Pilates and postural education group. PNE and graded exposure were feasible to implement. Between-group comparisons suggest higher improvements in the PNE group for extensor muscle endurance (p < .001, η2p = .29), pain catastrophizing (p < .001; η2p = .56) and fear-avoidance related to physical activity (p < .001; η2p = .48) and work (p < .001; η2p = .47). In the PNE group, at least 13 (76.5%) participants reported being at least "moderately better" against 6 (30%) participants in the Pilates group.

CONCLUSION

PNE and graded exposure can be successfully implemented in an occupational context and is potentially more beneficial than Pilates and postural education for extensor muscle endurance, catastrophizing, and fear avoidance and similarly as beneficial for pain intensity and disability. Further studies are needed to confirm these results.

Application effect of diversified health-promoting models on rehabilitation exercises for cervical spondylotic myelopathy

BACKGROUND

With improving living standards, the incidence of cervical spondylotic myelopathy (CSM) has become increasingly high.

OBJECTIVE

The study aims to explore the effect of diversified health-promoting models on rehabilitation exercises in patients with CSM after an operation.

METHOD

This was a randomized controlled trial, wherein 107 patients with CSM treated by neurosurgery were selected as the subjects. Of those, 52 patients in the control group adopted the conventional health-promoting model, while the remaining 55 patients in the intervention group adopted diversified health-promoting models. The effect of rehabilitation exercises in the two groups was evaluated according to the self-efficacy rehabilitation outcome scale, grip strength measurement of the affected limb, and Barthel index.

RESULTS

At Day 3 post-operation and before discharge, the self-efficacy management of rehabilitation exercises in the intervention group was better than that of the control group (P< 0.05). The grip strength measurement of the affected limb, Japanese Orthopedic Association score of the cervical vertebra, and Barthel index of the two groups at Day 3 post-operation were lower than before the intervention and were not statistically significant (P> 0.05). However, these three items before discharge were improved when compared with those of before intervention and were statistically significant (P< 0.05).

CONCLUSION

Postoperative rehabilitation exercises guided by the diversified health-promoting models for patients with CSM can improve the patients' self-efficacy management ability in rehabilitation exercises, help improve grip strength, and promote the recovery of cervical vertebra function, thereby improving the patients' quality of life.

Digital therapeutics-based lumbar core exercise for patients with low back pain: A prospective exploratory pilot study

Objective

This study aimed to implement a digital therapeutics-based approach based on motion detection technology and analyze the clinical results for patients with chronic low back pain (LBP).

Methods

A prospective, single-arm clinical trial was conducted with 22 patients who performed mobile app-based sitting core twist exercise for 12 weeks. Clinical outcomes were assessed using the visual analog scale (VAS) for LBP, Oswestry Disability Index-Korean version (K-ODI), and EuroQol-5 dimension 5-level version (EQ-5D-5L) every 4 weeks after the initiation of treatment. Laboratory tests for factors associated with muscle metabolism, plain X-ray for evaluating sagittal balance, and magnetic resonance imaging for calculating cross-sectional area (CSA) of back muscles were performed at pretreatment and 12 weeks post-treatment.

Results

The study population included 20 female patients with an average age of 45.77 ± 15.45 years. The clinical outcomes gradually improved throughout the study period in the VAS for LBP (from 6.05 ± 2.27 to 2.86 ± 1.86), K-ODI (from 16.18 ± 6.19 to 8.64 ± 5.58), and EQ-5D-5L (from 11.09 ± 3.24 to 7.23 ± 3.89) (p < 0.001, respectively). The laboratory test results did not show significant changes. Pelvic incidence (from 53.99 ± 9.70° to 50.80 ± 9.20°, p = 0.002) and the mismatch between pelvic incidence and lumbar lordosis (from 8.97± .67° to 5.28 ± 8.57°, p = 0.027) decreased significantly. Additionally, CSA of erector spinae and total back muscles increased by 5.20% (p < 0.001) and 3.08% (p = 0.013), respectively.

Conclusions

The results of this study suggest that the efficacy of digital therapy-based lumbar core exercise for LBP is favorable. However, further large-scale randomized controlled studies are necessary.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured and Standardized Education or Advice for Chronic Primary low back pain in Adults

PURPOSE

Evaluate benefits and harms of education/advice for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) assessing education/advice compared with placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of education/advice could be isolated). We conducted meta-analyses and graded the certainty of evidence.

RESULTS

We screened 2514 citations and 86 full text RCTs and included 15 RCTs. Most outcomes were assessed 3 to 6 months post-intervention. Compared with no intervention, education/advice improved pain (10 RCTs, MD = -1.1, 95% CI -1.63 to -0.56), function (10 RCTs, SMD = -0.51, 95% CI -0.89 to -0.12), physical health-related quality of life (HRQoL) (2 RCTs, MD = 24.27, 95% CI 12.93 to 35.61), fear avoidance (5 RCTs, SMD = -1.4, 95% CI -2.51 to -0.29), depression (1 RCT; MD = 2.10, 95% CI 1.05 to 3.15), and self-efficacy (1 RCT; MD = 4.4, 95% CI 2.77 to 6.03). Education/advice conferred less benefit than sham Kinesio taping for improving fear avoidance regarding physical activity (1 RCT, MD = 5.41, 95% CI 0.28 to 10.54). Compared with usual care, education/advice improved pain (1 RCT, MD = -2.10, 95% CI -3.13 to -1.07) and function (1 RCT, MD = -7.80, 95% CI -14.28 to -1.32). There was little or no difference between education/advice and comparisons for other outcomes. For all outcomes, the certainty of evidence was very low.

CONCLUSION

Education/advice in adults with CPLBP was associated with improvements in pain, function, HRQoL, and psychological outcomes, but with very low certainty.

Trials We Cannot Trust: Investigating Their Impact on Systematic Reviews and Clinical Guidelines in Spinal Pain

We previously conducted an exploration of the trustworthiness of a group of clinical trials of cognitive-behavioral therapy and exercise in spinal pain. We identified multiple concerns in 8 trials, judging them untrustworthy. In this study, we systematically explored the impact of these trials ("index trials") on results, conclusions, and recommendations of systematic reviews and clinical practice guidelines (CPGs). We conducted forward citation tracking using Google Scholar and the citationchaser tool, searched the Guidelines International Network library and National Institute of Health and Care Excellence archive to June 2022 to identify systematic reviews and CPGs. We explored how index trials impacted their findings. Where reviews presented meta-analyses, we extracted or conducted sensitivity analyses for the outcomes of pain and disability, to explore how the exclusion of index trials affected effect estimates. We developed and applied an 'Impact Index' to categorize the extent to which index studies impacted their results. We included 32 unique reviews and 10 CPGs. None directly raised concerns regarding the veracity of the trials. Across meta-analyses (55 comparisons), the removal of index trials reduced effect sizes by a median of 58% (Inter Quartlie Range (IQR) 40-74). 85% of comparisons were classified as highly, 3% as moderately, and 11% as minimally impacted. Nine out of 10 reviews conducting narrative synthesis drew positive conclusions regarding the intervention tested. Nine out of 10 CPGs made positive recommendations for the intervention(s) evaluated. This cohort of trials, with concerns regarding trustworthiness, has substantially impacted the results of systematic reviews and guideline recommendations. PERSPECTIVE: We found that a group of trials of CBT for spinal pain with concerns relating to their trustworthiness has had substantial impacts on the analyses and conclusions of systematic reviews and clinical practice guidelines. This highlights the need for a greater focus on the trustworthiness of studies in evidence appraisal. PRE-REGISTRATION: Our protocol was preregistered on the Open Science Framework: https://osf.io/m92ax/.

Adaption and validation of simplified Chinese version of the Low Back Pain Knowledge questionnaire (sC-LKQ)

Introduction

Low back pain (LBP) knowledge questionnaire (LKQ) was developed by a Brazilian research group in 2009. It has been cross-culturally adapted to many languages with good reliability and validity. This work aimed to translate and validate the LKQ into a simplified Chinese version and to evaluate the self-efficacy in LBP among Chinese participants from China and Hungary.

Methods

A total of 431 people participated in this research, which lasted from September 2021 to June 2022 and was conducted on the Credamo online platform. The simplified Chinese LKQ (sC-LKQ) was generated through translation and cross-cultural adaptation guidelines. The participants were selected to fill out demographic questions, the sC-LKQ, and the Roland-Morris Disability Questionnaire (RMDQ). The reliability and validity of the data were evaluated using SPSS 28.0.

Results

The sC-LKQ showed good internal consistency (Cronbach's alpha was 0.79), and the intraclass correlation value was 0.85. There were five components in the questionnaire with good construct validity. The scores of RMDQ had negatively correlated with sC-LKQ.

Conclusion

In the Chinese population, the sC-LKQ demonstrated excellent psychometric qualities and could be used to evaluate self-efficacy in clinical practice and research.

"Emerging Topics in Pain Medicine": Advancing Research and Patient-Centered Health Strategies

Pain, in all its various forms and manifestations, impacts the lives of millions worldwide [...].

Online information on chronic pain in 3 countries: an assessment of readability, credibility, and accuracy

Objectives

To assess the readability, credibility, and accuracy of online information on chronic pain in Australia, Mexico, and Nepal.

Methods

We assessed Google-based websites and government health websites about chronic pain for readability (using the Flesch Kincaid Readability Ease tool), credibility (using the Journal of American Medical Association [JAMA] benchmark criteria and Health on the Net Code [HONcode]), and accuracy (using 3 core concepts of pain science education: (1) pain does not mean my body is damaged; (2) thoughts, emotions, and experiences affect pain; and (3) I can retrain my overactive pain system).

Results

We assessed 71 Google-based websites and 15 government websites. There were no significant between-country differences in chronic pain information retrieved through Google for readability, credibility, or accuracy. Based on readability scores, the websites were "fairly difficult to read," suitable for ages 15 to 17 years or grades 10 to 12 years. For credibility, less than 30% of all websites met the full JAMA criteria, and more than 60% were not HONcode certified. For accuracy, all 3 core concepts were present in less than 30% of websites. Moreover, we found that the Australian government websites have low readability but are credible, and the majority provided all 3 core concepts in pain science education. A single Mexican government website had low readability without any core concepts but was credible.

Conclusion

The readability, credibility, and accuracy of online information on chronic pain should be improved internationally to support facilitating better management of chronic pain.

Effectiveness of Communication Strategies in the Management of Chronic Postsurgical Pain: Protocol for a Systematic Review and Meta-Analysis

Purpose

To describe the details of a systematic review to assess the current evidence about the efficacy of communication strategies on the prevention of chronic postsurgical pain (CPSP).

Methods

The protocol for this systematic review was based on the Cochrane Handbook methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations. A systematic search of the literature on electronic databases Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science (from the inception to 19 June 2022) was carried out using predefined search terms to identify relevant studies. This review will include randomized clinical trials or observational studies. The search strategy consisted of keywords and index terms related to "clinician", "communication" or "post-surgical pain". Inclusion criteria are as follows: randomized clinical trials or observational studies using a parallel group design that assess the efficacy of communication interventions in patients undergoing surgery and that assess pain and pain-related disability. We considered interventions that included any type of written, verbal, and non-verbal communication in combination with other interventions or without. Control groups may include no communication intervention or another intervention distinctly different. We excluded studies with follow-up duration of less than 3 months, patients aged <18 years, and studies for which no reviewer had language proficiency (eg, Chinese, Korean). Descriptive statistics will be used to summarize quantitative findings. Meta-analysis will only be considered if at least three studies used the same outcome with comparable interventions, as we expect a wide heterogeneity of study population and settings.

Conclusion

This systematic review and meta-analysis will be an important source for clinicians and researchers to understand the influence of communication to prevent CPSP.

Study Registration

This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42021241596.

Effectiveness of Pain Neuroscience Education in Patients with Chronic Musculoskeletal Pain and Central Sensitization: A Systematic Review

OBJECTIVE

To collect the available evidence about the effectiveness of pain neuroscience education (PNE) on pain, disability, and psychosocial factors in patients with chronic musculoskeletal (MSK) pain and central sensitization (CS).

METHODS

A systematic review was conducted. Searches were performed on Pubmed, PEDro, and CINAHL, and only randomized controlled trials (RCTs) enrolling patients ≥18 years of age with chronic MSK pain due to CS were included. No meta-analysis was conducted, and qualitative analysis was realized.

RESULTS

15 RCTs were included. Findings were divided for diagnostic criteria (fibromyalgia-FM, chronic fatigue syndrome-CFS, low back pain-LBP, chronic spinal pain-CSP). PNE has been proposed as a single intervention or associated with other approaches, and different measures were used for the main outcomes considered. Conclusions, practice implication: PNE is effective in improving pain, disability, and psychosocial factors in patients with fibromyalgia, chronic low back pain (CLBP)-especially if associated with other therapeutic approaches-and also in patients with CFS and CSP. Overall, PNE seems to be more effective when proposed in one-to-one oral sessions and associated with reinforcement elements. However, specific eligibility criteria for chronic MSK pain due to CS are still lacking in most RCTs; therefore, for future research, it is mandatory to specify such criteria in primary studies.

Translation and Validation of Low Back Pain Knowledge Questionnaire Among Hindi-Speaking Indian Women

Low back pain (LBP) is a common problem encountered among women worldwide. This research aimed at the cross-cultural translation, adaptation, and equivalence assessment of the Low Back Pain Knowledge Questionnaire (LBPKQ) in the Hindi language. The LBPKQ, originally in English (E-LBPKQ) was translated and validated in the Hindi language (H-LBPKQ). The forward-backward procedure was adapted from the recommended guidelines for cross-cultural adaptation of measures. Psychometric properties of the H-LBPKQ were evaluated among 250 Hindi-speaking Indian women with LBP. Test-retest reliability was evaluated in the first 161 participants of the study sample. The overall LBPKQ scores obtained a mean of 3.1 ± 1.1. The internal consistency was excellent for both E-LBPKQ and H-LBPKQ, with Cronbach's alpha of 0.983 (95% confidence interval [CI], 0.980-0.986) and 0.975 (95% CI, 0.970-0.979), respectively. Construct validity was good, with Kaiser-Meyer-Olkin value of 0.892 for E-LBPKQ and 0.852 for H-LBPKQ. Bartlett's test of sphericity (P < .0001) was significant for E-LBPKQ and H-LBPKQ. Two factors were extracted through principal component analysis. The H-LBPKQ is valid and reliable to assess LBP knowledge among Hindi speaking population. Low LBPKQ scores indicate poor LBP knowledge; hence, LBP sensitization is needed among Indian women.

Clarification of the "pain neuroscience education" concept in the management of patients with persistent low back pain: A scoping review

BACKGROUND

Patient education is a recommended treatment strategy for persistent low back pain (PLBP). Pain neuroscience education (PNE) is an emerging concept with boundaries still unclear.

OBJECTIVE

To clarify the PNE concept and identify its key characteristics in PLBP management.

METHODS

A systematic search was conducted using the following databases: Pubmed, ScienceDirect, Google Scholar, Cochrane, and Pedro.

INCLUSION CRITERIA

publications in English or French on pain neuroscience education and chronic low back pain, educational books cited in white literature. Three reviewers independently selected eligible studies for final inclusion. Numerical analysis and narrative synthesis were carried out from the extracted data.

RESULTS

From 919 identified publications, 54 were selected. Ten educational resources were added. PNE refers to a theoretical framework, a specific educational intervention, and an overall care approach. It is characterized by the intention to help the patient reconceptualize their PLBP from a tissue injury marker to a protective, neurobiological perspective, and then to increase adherence to biopsychosocial rehabilitation and normalize cognitive-behavioral responses. Pain sciences concepts are presented with an optimization of learning strategies.

CONCLUSION

PNE stands out from other educational and cognitive behavioral approaches through its objective of changing the pain concept.

Patient education materials for non-specific low back pain and sciatica: A systematic review and meta-analysis

INTRODUCTION

Guidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the effectiveness of PEMs on process, clinical, and health system outcomes for LBP and sciatica.

METHODS

Systematic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, trial registries and grey literature through OpenGrey. We included randomized controlled trials of PEMs for LBP. Data extraction, risk of bias, and quality of evidence gradings were performed independently by two reviewers. Standardized mean differences or risk ratios and 95% confidence intervals were calculated, and effect sizes pooled using random-effects models. Analyses of acute/subacute LBP were performed separately from chronic LBP at immediate, short, medium, and long-term (6, 12, 24, and 52 weeks, respectively).

RESULTS

27 studies were identified. Compared to usual care for chronic LBP, we found moderate to low-quality evidence that PEMs improved pain intensity at immediate (SMD = -0.16 [95% CI: -0.29, -0.03]), short (SMD = -0.44 [95% CI: -0.88, 0.00]), medium (SMD = -0.53 [95% CI: -1.01, -0.05]), and long-term (SMD = -0.21 [95% CI: -0.41, -0.01]), medium-term disability (SMD = -0.32 [95% CI: -0.61, -0.03]), quality of life at short (SMD = -0.17 [95% CI: -0.30, -0.04]) and medium-term (SMD = -0.23 [95% CI: -0.41, -0.04]) and very low-quality evidence that PEMs improved global improvement ratings at immediate (SMD = -0.40 [95% CI: -0.58, -0.21]), short (SMD = -0.42 [95% CI: -0.60, -0.24]), medium (SMD = -0.46 [95% CI: -0.65, -0.28]), and long-term (SMD = -0.43 [95% CI: -0.61, -0.24]). We found very low-quality evidence that PEMs improved pain self-efficacy at immediate (SMD = -0.21 [95% CI: -0.39, -0.03]), short (SMD = -0.25 [95% CI: -0.43, -0.06]), medium (SMD = -0.23 [95% CI: -0.41, -0.05]), and long-term (SMD = -0.32 [95% CI: -0.50, -0.13]), and reduced medium-term fear-avoidance beliefs (SMD = -0.24 [95% CI: -0.43, -0.06]) and long-term stress (SMD = -0.21 [95% CI: -0.39, -0.03]). Compared to usual care for acute LBP, we found high to moderate-quality evidence that PEMs improved short-term pain intensity (SMD = -0.24 [95% CI: -0.42, -0.06]) and immediate-term quality of life (SMD = -0.24 [95% CI: -0.42, -0.07]). We found low to very low-quality evidence that PEMs increased knowledge at immediate (SMD = -0.51 [95% CI: -0.72, -0.31]), short (SMD = -0.48 [95% CI: -0.90, -0.05]), and long-term (RR = 1.28 [95% CI: 1.10, 1.49]) and pain self-efficacy at short (SMD = -0.78 [95% CI: -0.98, -0.58]) and long-term (SMD = -0.32 [95% CI: -0.52, -0.12]). We found moderate to very low-quality evidence that PEMs reduced short-term days off work (SMD = -0.35 [95% CI: -0.63, -0.08]), long-term imaging referrals (RR = 0.60 [95% CI: 0.41, 0.89]), and long-term physician visits (SMD = -0.16 [95% CI: -0.26, -0.05]). Compared to other interventions (e.g., yoga, Pilates), PEMs had no effect or were less effective for acute/subacute and chronic LBP.

CONCLUSIONS

There was a high degree of variability across outcomes and time points, but providing PEMs appears favorable to usual care as we observed many small, positive patient and system impacts for acute/subacute and chronic LBP. PEMs were generally less effective than other interventions; however, no cost effectiveness analyses were performed to weigh the relative benefits of these interventions to the likely less costly PEMs.

Evaluating the effectiveness of a comprehensive education on low back pain treatment outcomes: A controlled clinical study

OBJECTIVES

To investigate the effect of integrating an individualized, evidence-based low back pain comprehensive education package on low back pain treatment outcomes.

DESIGN

Single-blind, controlled clinical study using the alternate allocation of patients.

SETTING

Outpatient clinic.

SUBJECTS

In total, 54 participants with chronic low back pain (46.75 ± 11.11 years, 80% females) were randomized to intervention (n = 27) or a control group (n = 27).

INTERVENTION

The intervention group received additional four one-hour low back pain-related education sessions to eight 45 minutesstandard physical therapy sessions over 4 weeks.

OUTCOME MEASURES

Assessed at baseline, post-intervention, and 3 months. Outcome measures included pain intensity (Visual Analogue Scale), knowledge (Low Back Pain Knowledge Questionnaire), attitude (the Back Pain Attitudes Questionnaire), disability (the Oswestry Disability Index), mental health symptoms (Depression Anxiety Stress Scale, DASS-21 scale), and fear-avoidance (Fear-Avoidance Beliefs Questionnaire).

RESULTS

The intervention group showed significantly lower pain intensity ((4 weeks (3.58 ± 1.50 vs. 5.54 ± 1.92), 3 months (3.21 ± 1.74 vs. 5.69 ± 2.51)), higher knowledge ((4 weeks (21.67 ± 2.12 vs. 11.62 ± 3.47), three months (22.08 ± 3.40 vs. 12.23 ± 3.24)), lower negative attitudes ((4 weeks (99.29 ± 11.02 vs. 134.31 ± 12.97), 3 months (102.92 ± 15.58 vs. 132.42 ± 17.79)), lower disability ((4 weeks (26.30 ± 11.37 vs. 45.14 ± 18.67), 3 months (22.83 ± 16.06 vs. 44.13 ± 15.02)), lower stress score ((4 weeks (3.54 ± 3.01 vs. 8.81 ± 5.19), 3 months (3.21 ± 3.22 vs. 7.21 ± 4.36)), lower anxiety ((4 weeks (2.63 ± 3.16 vs. 6.42 ± 4.75), three months (2.63 ± 3.80 vs. 5.73 ± 4.44)), lower depression ((4 weeks (2.42 ± 2.15 vs. 6.42 ± 3.68), three months (2.63 ± 4.18 vs. 7.08 ± 4.41)), and lower fear-avoidance ((4 weeks (13.88 ± 12.32 vs. 50.88 ± 23.25), three months (15.50 ± 16.75 vs. 54.65 ± 31.81)).

CONCLUSION

Integrating low back pain comprehensive education into standard physical therapy might optimize the treatment outcomes of low back pain.

Why Are Patients Not Doing Their Prescribed Home-Based Exercises? An Updated Review of the Factors Affecting Adherence to Prescribed Home-Based Exercise in Patients With Chronic Low Back Pain

Prescribed home-based exercise programs have been found to be an effective non-pharmacological treatment for the management of chronic low back pain. However, such programs rely on continued patient adherence to performing the exercises. The purpose of this integrative review is to present the key factors that influence adherence to prescribed home-based exercise for individuals with chronic low back pain. Searches of AMED, SPORTDiscus, CINAHL, MEDLINE, ScienceDirect, and Cochrane Library databases were performed for the period 2015 to 2021, using the following key search terms: exercise adherence, exercise compliance, exercise therapy, home-based exercise, chronic low back pain, and enabler, barrier or factor. Eight studies met the inclusion criteria and included Qualitative, Prospective Observation, Feasibility, Case Series and Randomised Controlled Trial studies. All participants were adults ranging from 18 to 85 years old with chronic low back pain and there was an overall female representation of 53.4%. Studies were assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. The findings highlighted 2 key factors influencing adherence to home-based exercise programs for individuals with chronic low back pain: (1) the need for practitioners to develop effective communication skills that focus on the individual’s needs, including personalisation of exercise programs aimed at an individual’s symptoms, lifestyle and treatment goals; and (2) follow-up feedback and support strategies via electronic (virtual) or face to face in-clinic and home visits. Adherence to home-based exercise programs requires effective practitioner communication and targeted follow-up support and feedback.

‘I am the educator and the learner at the same time’: a qualitative survey of the knowledge and use of adult learning theory in UK musculoskeletal physiotherapists' patient education

Background/Aims

Patient education is a core component of musculoskeletal care, yet broad definitions exist and effective delivery methods are unclear. Musculoskeletal physiotherapists' use of patient education has been described as individualised and collaborative, reflecting a person-centred model of care. However, discrepancies between perceived and actual practice, and therapist-centred approaches to education, have been observed. Little is known about the theoretical basis of musculoskeletal physiotherapists' patient education practice, yet the adult learning theory frames how adults interact with education and echoes the principles of person-centred care. The aim of this study was to analyse the use of adult learning theory to inform patient education practice among UK musculoskeletal physiotherapists.

Methods

This study used a novel, online questionnaire to collect quantitative and qualitative data from a self-selecting sample of UK musculoskeletal physiotherapists, using a multimodal recruitment strategy. Complete responses were provided by 66 participants. Categorical and narrative data were collected and descriptive and thematic analyses undertaken.

Results

Participants generally self-rated their educational competencies highly, with the exception of evaluating patient education. Participants were more familiar with reflective and self-directed learning than with other adult learning theories. Two main themes were described: implicit adult learning theory knowledge and challenges in applying adult learning theory.

Conclusions

The results suggest that musculoskeletal physiotherapists may have implicit knowledge of adult learning theory, yet challenges exist in applying them. This finding supports the establishment of ongoing training in educational skills for physiotherapists and could be used as a catalyst for musculoskeletal physiotherapists to reflect on their knowledge and use of adult learning theory.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care

Touch is recognised as crucial for survival, fostering cooperative communication, accelerating recovery, reducing hospital stays, and promoting overall wellness and the therapeutic alliance. In this hypothesis and theory paper, we present an entwined model that combines touch for alignment and active inference to explain how the brain develops "priors" necessary for the health care provider to engage with the patient effectively. We appeal to active inference to explain the empirically integrative neurophysiological and behavioural mechanisms that underwrite synchronous relationships through touch. Specifically, we offer a formal framework for understanding - and explaining - the role of therapeutic touch and hands-on care in developing a therapeutic alliance and synchrony between health care providers and their patients in musculoskeletal care. We first review the crucial importance of therapeutic touch and its clinical role in facilitating the formation of a solid therapeutic alliance and in regulating allostasis. We then consider how touch is used clinically - to promote cooperative communication, demonstrate empathy, overcome uncertainty, and infer the mental states of others - through the lens of active inference. We conclude that touch plays a crucial role in achieving successful clinical outcomes and adapting previous priors to create intertwined beliefs. The ensuing framework may help healthcare providers in the field of musculoskeletal care to use hands-on care to strengthen the therapeutic alliance, minimise prediction errors (a.k.a., free energy), and thereby promote recovery from physical and psychological impairments.

Compensatory biomechanics and spinal loading during dynamic maneuvers in patients with chronic low back pain

Purpose

This study explores the biomechanics underlying the sit-to-stand (STS) functional maneuver in chronic LBP patients to understand how different spinal disorders and levels of pain severity relate to unique compensatory biomechanical behaviors. This work stands to further our understanding of the relationship between spinal loading and symptoms in LBP patients.

Methods

We collected in-clinic motion data from 44 non-specific LBP (NS-LBP) and 42 spinal deformity LBP (SD-LBP) patients during routine clinical visits. An RGB-depth camera tracked 3D joint positions from the frontal view during unassisted, repeated STS maneuvers. Patient-reported outcomes (PROs) for back pain (VAS) and low back disability (ODI) were collected during the same clinical visit.

Results

Between patient groups, SD-LBP patients had 14.3% greater dynamic sagittal vertical alignment (dSVA) and 10.1% greater peak spine torque compared to NS-LBP patients (p < 0.001). SD-LBP patients also had 11.8% greater hip torque (p < 0.001) and 86.7% greater knee torque (p = 0.04) compared to NS-LBP patients. There were no significant differences between patient groups in regard to anterior or vertical torso velocities, but anterior and vertical torso velocities correlated with both VAS (r = − 0.38, p < 0.001) and ODI (r = − 0.29, p = 0.01). PROs did not correlate with other variables.

Conclusion

Patients with LBP differ in movement biomechanics during an STS transfer as severity of symptoms may relate to different compensatory strategies that affect spinal loading. Further research aims to establish relationships between movement and PROs and to inform targeted rehabilitation approaches.

Self-efficacy and Emotional Distress in a Cohort With Patellofemoral Pain

Background:

Patellofemoral pain (PFP) is commonly described and approached in biomechanical terms despite strong evidence that psychosocial factors such as kinesiophobia, emotional distress, and self-efficacy are important in long-standing musculoskeletal pain.

Purpose:

To describe levels of self-efficacy, emotional distress, kinesiophobia, and widespread pain in a cohort with long-standing PFP and determine their association with measures of pain, function, and health-related quality of life.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Included were 112 patients with PFP (age range, 16-40 years) who had been recruited to a randomized controlled trial. Seven baseline factors (patient sex, pain duration, number of pain sites throughout the body, kinesiophobia [Tampa Scale of Kinesiophobia], emotional distress [Hopkins Symptom Checklist], self-efficacy, and knee extension strength) were investigated for associations with the following outcomes: symptoms of PFP (Anterior Knee Pain Scale), pain (worst and usual), and health-related quality of life (5-level EuroQol-5 Dimensions [EQ-5D-5L]). We used bivariate models and multivariable linear regression models with a stepwise backward removal method to find associations with the outcomes. Internal validation was conducted, and adjusted coefficients after shrinkage are presented.

Results:

Of the study patients, 28% reported emotional distress (Hopkins Symptom Checklist ≥1.75), 69% reported multiple pain sites, and 33% had widespread pain. The kinesiophobia score was elevated, with a mean score of 35.4 ± 8.2. Self-efficacy was strongly associated with better function (Anterior Knee Pain Scale) and health-related quality of life (EQ-5D-5L) as well as lower pain scores in bivariate and multivariable models. Self-efficacy and emotional distress explained 50% of the variance in health-related quality of life (EQ-5D-5L).

Conclusion:

Our findings support other studies of PFP suggesting elevated levels of kinesiophobia and emotional distress and higher rates of widespread pain compared with the general population or pain-free controls. Higher self-efficacy was associated with better function and health-related quality of life. Together with emotional distress, it explained half the variance of health-related life quality. The results underline the importance of approaching these patients in a biopsychosocial model.

Registration:

NCT02114294 ( ClinicalTrials.gov identifier).

Does m-health-based exercise (guidance plus education) improve efficacy in patients with chronic low-back pain? A preliminary report on the intervention's significance

Background

The utilization of mobile health (m-health) has rapidly expanded during the COVID-19 pandemic, and there is still a lack of relevant clinical data pertaining to chronic low-back pain (CLBP) management. This study was designed to compare the effectiveness of m-health-based exercise (via guidance plus education) versus exercise (via guidance) during CLBP management.

Methods

Participants (n = 40) were randomly assigned to intervention and control groups. The intervention group received m-health-based exercise (via guidance plus education), whereas the control group received m-health-based exercise (via guidance). The exercise prescription video and educational content were sent to participants by the application (app), Ding Talk. Repeated-measures analysis of variance was used to test the baseline’s intervention effects, 6-week follow-up, and 18-week follow-up. We selected function (Roland and Morris Disability Questionnaire) and pain intensity (current, mean, and most severe Numeric Rating Scale in the last 2 weeks) as the primary outcomes, changes of negative emotion (depression, anxious), and quality of life as the secondary outcomes.

Results

Time’s significant effect was found in pain, function, and health-related quality of life in both groups, but time did not show significant interaction effects. Participants were able to use m-based education with their anxiety and depression after treatment, but the relief only lasted until week 6. No differences were found on the aspect of mental health-related quality of life.

Conclusion

Preliminary findings suggest that m-health-based exercise (via guidance) may be a convenient and effective method to treat CLBP. However, additional health education didn't help more. More rigorous controlled trials are needed to improve the therapeutic effect in future studies.

Trial registration

Chinese Clinical Trials Registry Number ChiCTR2000041459. Registered on December 26, 2020.

The Impact of Reassurance on Musculoskeletal (MSK) Pain: A Qualitative Review

BACKGROUND

The reassurance provided during patient-therapist interactions is significantly associated with psychosocial outcomes, including fear and increased confidence. Currently, there are no available reviews that discuss the impact of reassurance for patients with musculoskeletal (MSK) pain. The aim of the present review was to qualitatively synthesize themes around reassurance mechanisms, and the impact during the interaction between patients with MSK pain and therapists. A systematic search strategy was undertaken. Studies were included if they were qualitative or mixed methods studies, examining the patient-therapist consultation, in any MSK clinical setting, with any health care professional, for adult patients with acute to chronic MSK pain. A thematic synthesis was conducted and supported by a particular assessment using CERQual.

RESULTS

Twenty-four studies were included (451 patients). Certain themes that related to both positive and negative outcomes of reassurance were identified as well as themes that illustrate the mechanisms causative of the outcomes. Using CerQual, we identified the most supported outcomes.

CONCLUSIONS

Effective reassurance includes affectionate interactions such as therapeutic relationship building and interpersonal skills, an individualized patient-centered approach, education and the provision of self-management strategies. It should be noted that some interactions that use pathoanatomic models led patients to misinterpret the information provided, this created feelings of fear.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

The Concept of Pain Inventory for Adults (COPI-Adult): Assessing Knowledge and Beliefs Regarding Pain Science Education

OBJECTIVES

Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables.

MATERIALS AND METHODS

A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502).

RESULTS

The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change.

DISCUSSION

The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

Applicability of pain neuroscience education: Where are we now?

BACKGROUND

Explaining pain to patients through pain neuroscience education (PNE) is currently a widespread treatment studied in the musculoskeletal context. Presently, there is sufficient evidence supporting the effectiveness of PNE in patients with chronic musculoskeletal disorders. However, clinicians must pay attention to the actual possibility to transfer research findings in their specific clinical context.

OBJECTIVE

We analysed the applicability of results of studies focused on PNE, which has not been done previously.

METHODS

A detailed discussion on PNE applicability is provided, starting from published randomized controlled trials that investigated the effectiveness of PNE.

RESULTS

This paper markedly points out the awareness of clinicians on the need for an accurate contextualization when choosing PNE as an intervention in clinical practice.

Self-management at the core of back pain care: 10 key points for clinicians

BACKGROUND

A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

OBJECTIVE

In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

DISCUSSION

People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

Effects of behavioural exercise therapy on the effectiveness of multidisciplinary rehabilitation for chronic non-specific low back pain: a randomised controlled trial

BACKGROUND

The long-term effects of behavioural medical rehabilitation (BMR), as a type of multidisciplinary rehabilitation, in the treatment of chronic non-specific low back pain (CLBP) have been shown. However, the specific effects of behavioural exercise therapy (BET) compared to standard exercise therapy (SET) within BMR are not well understood. The aim of the study was to assess the effectiveness of BMR + BET compared to BMR + SET in individuals with CLBP in a two-armed, pre-registered, multicentre, parallel, randomised controlled trial (RCT).

METHODS

A total of 351 adults with CLBP in two rehabilitation centres were online randomised based on an 'urn randomisation' algorithm to either BMR + SET (n = 175) or BMR + BET (n = 176). Participants in both study groups were non-blinded and received BMR, consisting of an multidisciplinary admission, a psychosocial assessment, multidisciplinary case management, psychological treatment, health education and social counselling. The intervention group (BMR + BET) received a manualised, biopsychosocial BET within BMR. The aim of BET was to develop self-management strategies in coping with CLBP. The control group (BMR + SET) received biomedical SET within BMR with the aim to improve mainly physical fitness. Therapists in both study groups were not blinded. The BMR lasted on average 27 days, and both exercise programmes had a mean duration of 26 h. The primary outcome was functional ability at 12 months. Secondary outcomes were e.g. pain, avoidance-endurance, pain management and physical activity. The analysis was by intention-to-treat, blinded to the study group, and used a linear mixed model.

RESULTS

There were no between-group differences observed in function at the end of the BMR (mean difference, 0.08; 95% CI - 2.82 to 2.99; p = 0.955), at 6 months (mean difference, - 1.80; 95% CI; - 5.57 to 1.97; p = 0.349) and at 12 months (mean difference, - 1.33; 95% CI - 5.57 to 2.92; p = 0.540). Both study groups improved in the primary outcome and most secondary outcomes at 12 months with small to medium effect sizes.

CONCLUSION

BMR + BET was not more effective in improving function and other secondary outcomes in individuals with CLBP compared to BMR + SET.

TRIAL REGISTRATION

Current controlled trials NCT01666639 , 16/08/2012.

Female Gender Is Associated with a Higher Prevalence of Chronic Neck Pain, Chronic Low Back Pain, and Migraine: Results of the Spanish National Health Survey, 2017

OBJECTIVES

To assess the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and migraine headache (MH) in the Spanish population and to identify sociodemographic and health-related variables associated with CNP, CLBP, and MH.

DESIGN

Observational study.

SETTING

Spain.

SUBJECTS

A total of 22,511 persons 18 years of age or older (10,304 males and 12,207 females) who participated in the 2017 Spanish National Health Survey.

METHODS

Stratified three-stage sampling was applied. CNP, CLBP, and MH were the dependent variables. The analysis was conducted separately by gender. Sociodemographic features, self-perceived health status, lifestyle habits, comorbidities, and pain features were analyzed by using logistic regression models.

RESULTS

Females reported a higher prevalence of CNP, CLBP, and MH (P < 0.001) than males. For both sexes, anxiety and/or depression and poor self-rated health were associated with a significantly increased prevalence of CNP, CLBP, and MH. For CNP and CLBP, the identified associated factors were older age and limitations to usual activity. For CNP and MH, the most common associated factor was comorbid respiratory disease.

CONCLUSIONS

Our study identified several factors associated with CNP, CLBP, and MH in Spanish female and male adults, with potential implications for health care providers.

Effectiveness of perioperative pain science education on pain, psychological factors and physical functioning: A systematic review

OBJECTIVE

To synthesize the evidence on the effectiveness of pain science education on pain, psychological factors and physical functioning in adults who underwent surgery.

DATA SOURCES

A systematic literature search of English articles using PubMed/Medline, Embase, Web of Science Core Collection, and Cochrane Library.

REVIEW METHODS

The search strategy was constructed as follows: (((pain) AND (education)) OR (pain education)) AND (surgery). Only controlled quantitative studies in adults reporting outcome(s) on pain, psychological factors and/or physical functioning were included. Risk of bias was assessed using the Cochrane risk of bias tools. P-values and corresponding effect sizes for interaction-effect (time × group) portrayed the difference in change over time between groups were of interest. The last search was conducted on February 28, 2021.

RESULTS

Nine papers (n = 1078) were deemed eligible for this review. Two randomized controlled trials showed significant interaction effects. Breast cancer patients who had received one preoperative pain science education session showed a significant increase in postoperative pain compared to controls (P-value = 0.0394). Furthermore, psychological factors (pain catastrophizing and kinesiophobia) decreased in participants who had received pain science education before total knee arthroplasty, while this was not the case in the control group (P-value < 0.001, ƞ2p:0.11).

CONCLUSIONS

Overall, pain science education did not result in any significant postoperative effects on pain, psychological factors and/or physical functioning compared to controls. There is currently no strong evidence for the implementation of pain science education in the perioperative period.Registration number: PROSPERO: ID 161267, registration number CRD42020161267.

Patient education materials for non-specific low back pain and sciatica: a protocol for a systematic review and meta-analysis

INTRODUCTION

Low back pain accounts for more disability than any other musculoskeletal condition and is associated with severe economic burden. Patients commonly present with negative beliefs about low back pain and this can have detrimental effects on their health outcomes. Providing evidence-based, patient-centred education that meets patient needs could help address these negative beliefs and alleviate the substantial low back pain burden. The primary aim of this review is to investigate the effectiveness of patient education materials on immediate process, clinical and health system outcomes.

METHODS AND ANALYSIS

The search strategy was developed in collaboration with a librarian and systematic searches will be performed in MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus. We will also search trial registries and grey literature through the OpenGrey database. Study selection will include a title and abstract scan and full-text review by two authors. Only randomised controlled trials will be included in this review. Trials must include patients with low back pain or sciatica and investigate educational interventions with at least one of the following contrasts: (1) education alone versus no intervention; (2) education alone versus another intervention; (3) education in addition to another intervention versus the same intervention with no education. Data extraction, risk of bias and grading of the quality of evidence will be performed independently by two reviewers. Risk of bias will be assessed using the PEDro scale, and the quality of evidence will be assessed with the Grades of Recommendation, Assessment, Development and Evaluation approach. A random-effects model will be used for each contrast, and results will be pooled if the participants, interventions, and outcomes are homogeneous. If heterogeneity is high (I2 >75%), we will evaluate the magnitude and direction of the differences in effect sizes across studies to determine if it remains reasonable to pool the results. Analyses of acute and subacute low back pain (less than 12 weeks duration) will be performed separately from chronic low back pain (12 weeks or greater duration). Likewise, analyses of short-term (less than 6 months) and long-term (6 months or greater) follow-up will be performed separately. Subgroup analyses will be performed on non-specific low back pain, sciatica and mixed populations.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. This study, along with its results, will be published in a peer-reviewed journal.